Closing the gap: Addressing LGBTQ health disparities from both sides

By Erin Rook, PQ Monthly

Going to the doctor makes most people uncomfortable, but for LGBTQ folks, that anxiety is heightened by a fear of ignorance, discrimination, and denial of care.

These fears are not unfounded. At the recent Meaningful Care Conference, hosted by the LGBTQ Heath Coalition of the Columbia-Willamette, Multnomah County Commissioner Deborah Kafoury explained why the conference is so important.

“LGBTQ people are often reluctant to seek out health care and come out to providers,” Kafoury said in her opening remarks. “LGBTQ people face documented structural, financial, and cultural barriers to access healthcare services.”

The only conference of its kind in the Northwest, the Meaningful Care Conference offers a diverse range of workshops intended to give healthcare providers and advocates the skills to provide culturally competent care for LGBTQ people.

Offerings include such diverse topics as “Supporting Survivors of Domestic & Sexual Violence in LGBT & Queer Communities of Color,” “Organizing to Improve the Health of Rural LGBTQ Individuals,” “Best Practices for Supporting Transgender Children and Their Families in Social Services and Health Care,” and “Substance Use and the LGBTQ Community.

Shane Snowdon, director of the UCSF Center for LGBT Health and Equity, delivered a lively keynote speech on the progress made in LGBT equality and the challenges left to overcome. Photo by Xilia Faye, PQ Monthly.

But before participants delved into the material, a panel of LGBTQ healthcare consumers provided context by sharing the challenges they have faced in receiving appropriate, respectful care.

The first panelist, John Motter, related the ignorance and discrimination he has faced as an HIV-positive gay man in recovery. He also encouraged audience members by explaining that providing quality care often has more to do with a provider’s approach than level of knowledge.

“I don’t expect the medical profession to know everything about how to treat me, but how to treat me with respect,” Motter said. “I’m never offended when they need to ask me questions, only offended when they make assumptions.”

Those assumptions can have serious consequences. For panelist Maurice Evans, a black bisexual man who is also HIV-positive and in recovery, they may well have ended his marriage.

While living in Texas, his wife (from whom he has been estranged for eight years) developed an infection as a result of a latex allergy. That infection was passed on to Evans, who then went to the doctor for treatment.

“He says I have chlamydia, treats me for chlamydia. I have to go back to my wife, who I’m supposed to be monogamous with and say I have chlamydia. That’s what broke our marriage up,” Evans said. “But it was actually a [urinary tract infection]. It just speaks to the presumption he made about me being a black man and diseased.”

Discrimination by healthcare professionals doesn’t just lead to mistreatment of LGBTQ folks, it sometimes leads to no treatment at all. According to the National Transgender Discrimination Survey, 19 percent of respondents were actually refused care due to their trans identity or gender presentation. And 28 percent postponed medical care in an effort to avoid mistreatment. A full half of those surveyed said that had to teach their medical providers about transgender care.

What’s a queer to do?

First, find hope in the fact that nearly 400 providers and advocates showed up to the conference to get educated on how to better serve their LGBTQ patients/clients.

The next conference will be during National LGBTQ Health Equality Week in 2014. In the meantime, the LGBTQ Heath Coalition of the Columbia-Willamette is working toward its three primary goals: supporting LGBTQ cultural competency, raising awareness about health disparities, and advocating for health equality.

“We are currently working to disseminate action sheets outlining LGBTQ health disparities in Oregon using Oregon-specific data,” says coalition coordinator Dayna Morrison. “These action sheets will reflect the diversity of the health concerns and community demographics. The first sheet focuses on LGBTQ community elders, and will be followed by action sheets on chronic health conditions, substance abuse and mental health challenges, and other community specific concerns in preparation for the 2013 Oregon legislative sessions, where we intend to support LGBTQ health equity. We are also involved in Oregon Health reform and have representatives sitting on work groups at the Oregon Health Authority to ensure LGBTQ concerns are not overlooked in the health reform process.”

While healthcare professionals are increasingly educating themselves about the needs of their LGBTQ patients, individuals also have a responsibility to speak up and be honest about their experiences, needs, and desires.

PQ Monthly asked a handful of queer-identified healthcare professionals and advocates for their advice on identifying LGBTQ-friendly providers, overcoming barriers to care, and learning to advocate for our own healthcare needs. Here’s what they had to say.

Do your homework

Most LGBTQ folks don’t have the privilege of being able to draw a provider’s name from a hat and expect quality care. But healthcare needn’t be left to the luck of the draw. Queer-savvy providers are out there, you just need to know where to look.

“For most people, networking and asking friends is fairly easy,” says José Cruz, R.N., who works with the Trans Clinic at Outside In. “I would say start there; ask friends who they recommend.”

But what if your friends’ providers are out of network or out of your budget? Or you don’t know anyone with your particular health needs?

“My advice would be to go online,” says Ernesto Domínguez, youth technology specialist at Cascade AIDS Project. The websites for Resources PDX, the Gay and Lesbian Medical Association, and the World Professional Association for Transgender Health all offer referrals for LGBTQ-friendly providers (see sidebar for more details).

When searching online, it’s wise to call to confirm that the provider is still practicing and accepting new patients. While you’re on the phone, consider calling local health organization such as Outside In and CAP for referrals or checking with your healthcare network to see which providers self-identify as LGBTQ-friendly.

For example, the Trans Clinic has closed its waiting list due to high demand, but Cruz is still able to help people find care elsewhere.

“Much of the work that I do at the Trans Clinic at Outside In is help people with referrals to providers within their insurance network that have experience with trans folks,” Cruz says. “At the request of clients who’ve contacted me, I’ve also contacted provider offices and directed them to professional resources on primary care for transgender patients and let them know that they would be having a new client who is transgender coming to them for primary care.”

“I have people who have contacted me from different parts of Oregon that I’ve been able to refer to a provider that is closer to them that has experience with trans patients,” he adds.

If you can’t get a referral, take matters into your own hands. Interview providers over the phone to make sure they can provide the care you need.

“Here’s [a question to ask]: Do you have experience working with people like me? Explain!” suggest LGBTQ health providers and advocates Wendy and Carol Blenning (read PQ’s profile of the couple here).

In addition to researching providers, brush up on your knowledge of the health issues you currently have or are at increased risk for, as well as any screenings you should be getting. That way, you’ll know whether or not you’re getting the care you need.

Not sure what those health issues are? The Gay and Lesbian Medical Association has handy guides on its website outlining the top 10 issues gay men, lesbians, and trans folks should discuss with their provider. While patients are not expected to be medical experts, the more you know about your healthcare needs, the better you can assert them.

“These are great tools for LGBTQ folks to educate and empower themselves before going in to see a medical provider,” Domínguez says.

But that doesn’t mean LGBTQ folks should expect to play the role of teacher.

“You as a client/patient should never be expected to provide training for your provider on how to handle your medical treatment,” Cruz says. “Of course, you should be an active part of your treatment but this doesn’t mean providing medical training for your provider.”

Be honest

Coming out to a stranger while wearing a paper “gown” can be awkward at best. But LGBTQ providers and advocates seem to agree that honesty is the best policy, as long as it doesn’t put you in harms way.

“Any time that your sexual orientation or gender identity might affect the care you need or your risk for various things, I would recommend that you share as much information as you feel comfortable,” Dominguez says. “For a provider to diagnose/treat you effectively they have to know as much about you as possible.”

On the other hand, there are times your provider probably doesn’t need to know your sexual orientation or gender identity. This is especially true when seeing a specialist who may have less need for that information than a primary care provider.

“The decision comes down to client comfort and whether or not the disclosure is necessary for medical care,” Cruz says. “For example, when I dislocated my knee, I didn’t feel it was necessary to disclose trans status to urgent care, but if I was going to a urinary specialist, I would probably want the specialist to know ahead of time.”

But how exactly do you come out to your provider, especially if they don’t ask about your gender or sexual identity? Cruz recommends keeping it simple and nonchalant.

“I’ll just say something like, ‘So before we get started, I just want you to know that I’m a transmale.’ My philosophy is to say it in a way that normalizes trans status as just another part of a person’s history, a part of who they are,” Cruz says. “A healthcare provider who is competent shouldn’t bat an eye at this. The best response I’ve gotten when I’ve done this is, ‘Thanks for letting me know,’ and then we moved on to my reason for being in the office.”

And even when it’s relevant, there are lines of questioning you should never have to field. Don’t be afraid to ask your provider why they need to know what they are asking. If it’s a matter of voyeuristic curiosity, encourage them to do research on their own time. After all, you’re paying them for their time, not the other way around.

Assert your needs

Of course, coming out isn’t a guarantee that your provider will offer the necessary tests and screenings, especially if they don’t normally treat LGBTQ folks. In order to combat misinformation (such as the all-too-common belief that STDs like HPV can’t be spread between women or trans hormone therapy must be provided by an endocrinologist) be upfront about your needs and prepared to back them up.

This means being clear about the words you want the provider to use in reference to you and your parts and the tests you’d like done.

“If you are unsure of the level of competency of your provider and you are going in for an STD check-up, I might suggest you go in with a list of what procedures you want done,” Domínguez says. “A provider may just assume that you need say, a test for urethral gonorrhea or chlamydia because that is the standard for most heterosexual men but they may fail to give you a test for these same diseases in your throat or rectum because they don’t know the full extent of your sexuality or sexual behaviors.”

Being assertive means not only being upfront about your needs, but being clear when they aren’t being met. No one deserves to put up with mistreatment from a healthcare provider.

“You have the right to safe, competent, sensitive medical care,” Cruz says. “If your provider or other staff in the office says something or treats you in a way that you feel uncomfortable, you have the right to say something. It’s ok to not address it in the moment if it feels too intense. You can leave the office, write a letter to the doctor, make a phone call later, [or] ask for an additional face-to-face appointment where you address your concerns. If you feel that you’re not getting your needs met, say something.”

Spread the word

When you find a healthcare provider that gets you, pay it forward.

“I’d encourage folks to tell their providers who they think are great and LGBTQ-competent, but may not be in one of these directories or advertising in gay-friendly media, to get the word out there about their practices,” Domínguez says. “There are a lot of LGBTQ folks in the Portland area who need health care and are looking for providers to serve them.”

The Trans Clinic provides sliding-scale acute health care, family planning, HIV/STD testing, and hormone therapy for trans, genderqueer, queer, and questioning people ages 18+ with no insurance. The waiting list is currently closed, but the clinic still offers resources and referrals.